Part-time Employee Benefits Enrollment Guide

Congratulations, you are eligible for Employee Benefits! RPCS, Inc.’s group benefit program will be renewing effective January 1, 2016 through December 31, 2016. This is our “annual enrollment period” for eligible employees to confirm their benefits, make changes or enroll in the health benefits offered through your employer. Part-time employees are eligible for the following benefits:  Transamerica  Minimum Essential Coverage (MEC)  Limited Medical Plan  Anthem Voluntary Dental  VSP Voluntary Vision  Aflac Hospital Indemnity Insurance  Transamerica Cancer Insurance  Trustmark voluntary  Universal Life  Accident Insurance  Critical Illness

Please contact your Store Director or RPCS, Inc.’s Human Resource Department at 417-829-9200 if you have eligibility questions.

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Who is Eligible? If you are considered a part-time employee who has met the eligibility waiting period and you met the required work hours per week, you are eligible to enroll in the benefits described in this guide.

Proof of a dependent’s continued eligibility may be requested at any time. Failure to provide the required proof of dependent eligibility will result in loss of dependent coverage in these benefit plans. Below is a description of eligible dependents.

DEPENDENT EILIGITY REQUIREMENTS Spouse: Your legally married spouse. Includes a common law spouse where recognized under applicable state law. Children: Your child or your legal spouse’s child who is unmarried. Includes a child by birth, an adopted child, a child under the age of 18 who has been placed with you for the purpose of adoption, or a child placed with you under legal guardianship. Disabled Children: Your child or your legal spouse’s child who is unmarried and who has reached the limiting age who cannot support him/herself because of a physical or mental disability. The disability must have started before the end of the Calendar Year in which the child reached the limiting age and the child must have been continuously covered under the plan at the time of reaching the limiting age. Qualified Medical Support Order: Refers to your child or your legal spouse’s child who is unmarried and for whom a Qualified Medical Support Order has been issued.

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WAIVER OF INSURANCE COVERAGE I have been offered to participate in benefits for me and my eligible dependents by my employer, RPCS, Inc. I am waiving my right to participate in: 

Transamerica Minimum Essential Coverage (MEC)



Transamerica Limited Medical



Anthem Voluntary Dental



VSP Voluntary Vision



Aflac Hospital Indemnity Insurance



Transamerica Cancer Insurance



Trustmak Voluntary Products

Because: 

I am covered by my spouse or parent’s insurance program.



I am covered on an individual policy



I have other insurance through (i.e. Medicaid, CHAMPUS, Medicare or Tricare)



I do not desire to enroll at this time and have no other insurance.

I understand by declining to participate in the above coverages at this time may cause me and/or my eligible dependents to be late entrants for the declined coverages. I also understand that carrier approval may be required for me and/or my eligible dependents to participate at a later date.

Employee Signature Employee Name (Print)

Date

Complete this form and turn it in to RPCS, Inc.'s Human Resource Department. 4

Benefits Enrollment Worksheet Complete this form and turn it in to RPCS, Inc.'s Human Resource Department.

Employee Print Full Name

Sign and Date

The information requested below is being collected because of two Federal Requirements. 1. Affordable Healthcare requires the requested information for all employees and their dependents. 2. Federal requirements by the CMS, Medicare and Medicaid for any employee and dependent indicating enrollment in a medical plan. Please indicate yes or no below if your dependent spouse and/or child(ren) have other medical insurance coverage available to them. This coverage would be offered through an employer, other parent coverage, Medicare, Medicaid. Relationship

LEGAL NAME

(Spouse, Child)

(Last, First)

Social Security Number

Other medical insurance available

Date of Birth (MM/DD/YYYY)

Gender (M/F)

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How to Enroll Complete an enrollment form for the benefits you want to enroll in and return the completed forms to the Human Resource Department within 31 days of your eligibility. You must make your benefit elections or waive coverage. Once you have made your elections, you will not be able to change them until the next open enrollment period unless you have a qualified change in status.

When to Enroll You must enroll in your benefits within 31 days of your becoming eligible for benefits. Benefit plan year is January 1st to December 31st.

How to Make Changes Unless you have a qualified change in status, you cannot make changes to the benefits you elect until the next annual enrollment period. Qualified changes in status include: marriage, divorce, legal separation, birth or adoption of a child, change in child’s dependent status, death of spouse, child, and a change in residence due to an employment transfer for you or your spouse, commencement or termination of adoption proceedings, a change in your spouse’s benefits or a change in your or your spouse’s employment status.

The information in this Enrollment Guide is presented for illustrative purposes and is based on information provided by the employer. The text contained in this Guide was taken from various summary plan descriptions and benefit information. While every effort was taken to accurately report your benefits, discrepancies or errors are always possible. In case of discrepancy between the Guide and the actual plan documents the actual plan documents will prevail. All information is confidential, pursuant to the Health Insurance Portability and Accountability Act of 1996. If you have any questions about your Guide, contact Human Resources. 6

Benefits: 

Transamerica - Minimum Essential Coverage (MEC) – Minimum Essential Coverage (MEC) covers 100% of the CMS listed Preventative and Wellness benefits when you visit a network provider (40% out-of-network). An employee can prevent being taxed the “Individual Mandate” coverage penalty by purchasing Minimum Essential Coverage through his/her employer. Employees will face a tax, the greater of 2.5% of adjusted household income or $695 per adult plus $347.50 per child.



Transamerica – Limited Medical – The limited medical plan includes TeleDoc a national network of board certified physicians. Please see benefit section of this book for more information. THIS IS NOT MAJOR MEDICAL INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL INSURANCE. IT DOES NOT QUALIFY AS MINIMUM ESSENTIAL HEALTH COVERAGE UNDER THE FEDERAL AFFORDABLE CARE ACT AND WILL NOT EXEMPT YOU FROM THE “INDIVIDUAL MANDATE” TAX.



Anthem Voluntary Dental



VSP Voluntary Vision



Aflac Hospital Indemnity Insurance



Transamerica Cancer Insurance



Trustmark Voluntary – Universal Life, Accident Insurance, and Critical Illness

Please see the following pages for more information regarding the benefits available.

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Dental The Voluntary Dental plan is offered through Anthem. The Anthem dental plan lets you visit any licensed dentist or specialist you want – with costs that are normally lower when you choose a provider within Anthem’s large network. You can find a provider by going to www.anthem.com/ca/mydental or calling Anthem dental customer service at 877-567-1804.

Tier Employee Only Family

Voluntary Dental Rates Total Weekly Premium Employee Weekly Rate $4.87 $4.87 $13.98 $13.98

Employer Weekly Cost $0.00 $0.00

The above illustrated rates will go into effect January 1, 2016.

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Voluntary Vision All eligible fulltime and part-time employees will again be offered a comprehensive Voluntary Vision plan through VSP. VSP has an extensive network that will accommodate our diverse geographic employee population. Benefits through a VSP Choice Preferred Provider or Retail affiliate provider

Providers

Choice Network 30,000 VSP Choice Preferred Providers 50,000 access points ® More than 600 Visionworks locations, approximately 400 Costco Optical locations, and additional affiliate locations ®

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Thorough VSP WellVision Exam covered in full

Exam Services

Contact lens exam (fitting and evaluation): 2 Standard fit: Covered in full after copay. Member receives 15% off of contact lens exam services ; member's copay will never exceed $60 2

Premium fit: Covered in full after copay. Member receives 15% off of contact lens exam services ; member's copay will never exceed $60 Guaranteed pricing, ensuring that members won't pay more than $39 for a routine retinal screening at a VSP Choice Preferred Provider

Lenses

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Glass or plastic, single vision, lined bifocal, lined trifocal, or lenticular prescription lenses are covered in full

Most popular lens options are covered in full with a copay, saving our members an average of 20-25%

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2,4

Lens Options

Patient cost: Progressives: $55 copay Anti-reflective: $41 copay Photochromics: $47 copay Scratch resistant coating: $17 copay Polycarbonate: $31 copay

Dependent children are eligible for covered in full polycarbonate prescription lenses 1

Frames are covered in full up to the retail allowance of $150

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®

Frame

Extra $20 on featured brands like bebe , ck Calvin Klein, Flexon, Lacoste, Michael Kors, Nike, Nine West and 1 5 more. These will be covered in full up to the retail allowance of $170 . 2

20% off any amount above the allowance

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20% off unlimited additional pairs of prescription glasses and/or non-prescription sunglasses

Instead of eyeglasses, elective contact lens materials are covered up to $150 toward any type of prescription contact lenses 8

Contact Lenses

Exclusive offers for VSP members at a VSP Choice Preferred Provider include: Mail-in rebate savings up to $60 on eligible Bausch & Lomb contacts and up to $125 on eligible ACUVUE Brand Contact Lenses 1

Necessary contact lenses are covered in full for members who have specific conditions for which contact lenses provide better visual correction Members may use their open access schedule at Retail affiliate providers

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Voluntary Vision Rates Tier Employee Only Family

Total Weekly Premium $1.22 $3.38

Employee Weekly Rate $1.22 $3.38

Employer Weekly Cost $0.00 $0.00

Voluntary Benefits Our Voluntary Benefits will be made available through Aflac, Transamerica, and Trustmark. The Worksite Benefit Associates (WBA) enrollment counselors will provide you with all the information you need to make the benefit choice that fits your individual needs.

Announcing OPEN ENROLLMENT for the following Trustmark Voluntary Benefits! Even if you did not previously enroll when first eligible, this one-time offer allows you to enroll at this time. Please note: if you were denied coverage in the past, you will be asked the same SI questions as before and could be denied coverage again.

All eligible full-time and part-time employees will be offered a comprehensive Voluntary Benefit Program through Trustmark. With 100 years in the voluntary market, Trustmark is committed to providing efficient products and service. The following options will be available to RPCS employees and enrolled by the Worksite Benefit Associates: 

Universal Life – Permanent life insurance for employees and their spouses in face amounts from $5,000 up to $300,000. Employees do not have to have coverage themselves to purchase life insurance for their family members.



Accident Insurance – This insurance helps pay for unexpected healthcare expenses due to accidents that occur every day while off the job. Accident insurance provides benefits due to covered accidents for initial care, injuries and follow-up care. Benefits are paid directly to the employee, in addition to any other medical coverage.



Critical Illness with Cancer – This insurance offers a lump-sum benefit payment upon first diagnosis of a covered critical illness including but not limited to:    



Cancer Stroke Heart Attach Renal Failure

Disability Income – This non-occupational coverage will provide benefits for employees when they are unable to work due to a covered illness or injury.

Please be sure to review these benefits offered through Trustmark with your WBA enrollment counselor. 1 0

NEW THIS YEAR! New this year, we are offering voluntary Hospital Indemnity Insurance through Aflac, and voluntary Cancer Insurance through Transamerica. Hospital Indemnity Plan Features

plan pays regardless of any other insurance programs.

-day hospital confinement benefits are included. Additional benefits are paid for confinement to intensive care.

ulations). This proposal is a brief description of coverage, not a contract. Read your policy carefully for exact plan language, terms, and conditions

Cancer Insurance Plan Features

Chances are someone in your company has been diagnosed with cancer. When those medical emergencies occur, oftentimes people are suddenly faced with lengthy medical treatment, drastic lifestyle changes and uncertain futures. This helps prepare you for such an occurrence by offering supplemental cancer only insurance specifically designed to provide meaningful direct and indirect medical benefits. CancerSelect Plus benefits are paid in addition to any other insurance and are paid directly to the employee or directly to anyone else the employee chooses. Please ask your benefits counselor for more details. Please be sure to review these benefits offered through Aflac and through Transamerica with your WBA enrollment counselor.

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ENROLLMENTGUIDE

FOR THE EMPLOYEES OF

RPCS, Inc. 10

Minimum Essential Coverage Minimum Essential Coverage (MEC) covers 100% of the CMS listed Preventative and Wellness benefits when you visit a network provider (40% out-of-network). An employee can prevent being taxed the “Individual Mandate” coverage penalty by purchasing Minimum Essential Coverage through his/her employer. If not, the tax will be the greater of 2.5% of adjusted household income or $695 per adult plus $347.50 per child. First dollar coverage with access to one of the largest national provider networks available (simple web portal for member’s local or out-of-town provider look up) with great discount savings for MEC benefits. Network savings can be used for services not covered by MEC.

Minimum Essential Coverage (MEC) Self-Insured by your employer, this coverage is required to satisfy the individual mandate under Health Care Reform Weekly Cost† Employee Employee + 1 Family

MEC $12.26 $19.21 $42.88

† Rates assume cost is currently and will continue to be remitted in advance of the effective date. Rates include administrative fees for continuation, enrollment and materials.

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What are the Covered Services in Minimum Essential Coverage 15 Covered Preventive Services for Adults 1. Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked 2. Alcohol Misuse screening and counseling 3. Aspirin use for men and women of certain ages 4. Blood Pressure screening for all adults 5. Cholesterol screening for adults of certain ages or at higher risk 6. Colorectal Cancer screening for adults over 50 7. Depression screening for adults 8. Type 2 Diabetes screening for adults with high blood pressure 9. Diet counseling for adults at higher risk for chronic disease 10. HIV screening for all adults at higher risk 11. Immunization vaccines for adults--doses, recommended ages, and recommended populations vary: o Hepatitis A o Hepatitis B o Herpes Zoster o Human Papillomavirus o Influenza (Flu Shot) o Measles, Mumps, Rubella o Meningococcal o Pneumococcal o Varicella o Tetanus, Diphtheria, Pertussis 12. Obesity screening and counseling for all adults 13. Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk 14. Tobacco Use screening for all adults and cessation interventions for tobacco users 15. Syphilis screening for all adults at higher risk

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22 Covered Preventive Services for Women, Including Pregnant Women 1. Anemia screening on a routine basis for pregnant women 2. Bacteriuria urinary tract or other infection screening for pregnant women 3. BRCA counseling about genetic testing for women at higher risk 4. Breast Cancer Mammography screenings every 1 to 2 years for women over 40 5. Breast Cancer Chemoprevention counseling for women at higher risk 6. Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women 7. Cervical Cancer screening for sexually active women 8. Chlamydia Infection screening for younger women and other women at higher risk 9. Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs 10. Domestic and interpersonal violence screening and counseling for all women 11. Folic Acid supplements for women who may become pregnant 12. Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes 13. Gonorrhea screening for all women at higher risk 14. Hepatitis B screening for pregnant women at their first prenatal visit 15. Human Immunodeficiency Virus (HIV) screening and counseling for sexually active women 16. Human Papillomavirus (HPV) DNA Test: high risk HPV DNA testing every three years for women with normal cytology results who are 30 or older 17. Osteoporosis screening for women over age 60 depending on risk factors

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Covered Services (continued) 18. Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk 19. Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users 20. Sexually Transmitted Infections (STI) counseling for sexually active women 21. Syphilis screening for all pregnant women or other women at increased risk 22. Well-woman visits to obtain recommended preventive services 26 Covered Preventive Services for Children 1. Alcohol and Drug Use assessments for adolescents 2. Autism screening for children at 18 and 24 months 3. Behavioral assessments for children of all ages Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 4. Blood Pressure screening for children Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 5. Cervical Dysplasia screening for sexually active females 6. Congenital Hypothyroidism screening for newborns 7. Depression screening for adolescents 8. Developmental screening for children under age 3, and surveillance throughout childhood 9. Dyslipidemia screening for children at higher risk of lipid disorders Ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, and 15 to 17 years. 10. Fluoride Chemoprevention supplements for children without fluoride in their water source 11. Gonorrhea preventive medication for the eyes of all newborns 12. Hearing screening for all newborns 13. Height, Weight and Body Mass Index measurements for children Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.

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14. Hematocrit or Hemoglobin screening for children 15. Hemoglobinopathies or sickle cell screening for newborns 16. HIV screening for adolescents at higher risk 17. Immunization vaccines for children from birth to age 18 —doses, recommended ages, and recommended populations vary: o Hepatitis A o Diphtheria, Tetanus, Pertussis o Hepatitis B o Haemophilus influenzae type b o Human Papillomavirus o Inactivated Poliovirus o Influenza (Flu Shot) o Measles, Mumps, Rubella o Meningococcal o Pneumococcal o Rotavirus o Varicella 18. Iron supplements for children ages 6 to 12 months at risk for anemia 19. Lead screening for children at risk of exposure 20. Medical History for all children throughout development Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 21. Obesity screening and counseling 22. Oral Health risk assessment for young children Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years. 23. Phenylketonuria (PKU) screening for this genetic disorder in newborns 24. Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk 25. Tuberculin testing for children at higher risk of tuberculosis Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 26. Vision screening for all children

15 EBD GHINRPCS 1013

These two plan options are designed for sale in conjunction with Minimum Essential Coverage (MEC).

Daily In-Hospital Indemnity Benefit Per day (max of 31 days per confinement) Surgical and Anesthesia Indemnity Benefit Pays benefit per day, 1 day per calendar year for Inpatient Surgery; Pays one half the benefit per day, 1 day per calendar year for Outpatient Surgery; Pays one-tenth the benefit per day, 1 day per calendar year for Specified Outpatient Surgeries; Pays additional 20% of the surgical benefit for Anesthesia. Off-the-Job Accidental Injury Benefit Pays benefit per day of accident treatment (5 days per calendar year) Hospital Confinement 1 day of confinement per year Intensive Care Indemnity Benefit Per day (Annual maximum of 31 days)

Non-Insurance Benefits Included Employee Discount Card - Offered by New Benefits, LTD Provides access to a discount Vision plan, Nurses Hotline, Counseling Services, and discounts on Hearing Aids Patient Advocacy - Offered by The Karis Group Services that provide employees with unparalleled diligence and dedication to find the best solutions for resolving their outstanding medical bills TelaDoc™ TelaDoc™ is a national network of board certified physicians providing cross coverage consultations 24 hours a day, 365 days a year.

Weekly Premiums† Employee Employee + Spouse Employee + Child(ren) Family

Plan 1

Plan 2

$100

$100

$1,000

$1,000

$500

$500

N/A

$1,000

N/A

$200

Plan 1

Plan 2

$7.89 $15.00 $12.35 $17.98

$10.84 $21.49 $16.78 $25.37

This is a brief summary of TransChoice® Advance Limited Benefit Hospital Indemnity Insurance underwritten by Transamerica Life Insurance Company, Cedar Rapids, IA. Forms and form numbers may vary. Coverage may not be available in all jurisdictions. Limitations and exclusions apply. Refer to the policy, certificate and riders for complete details. Rates shown include insurance premiums and administrative fees for continuation and billing costs.

THIS IS NOT MAJOR MEDICAL INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL INSURANCE. IT DOES NOT QUALIFY AS MINIMUM ESSENTIAL HEALTH COVERAGE UNDER THE FEDERAL AFFORDABLE CARE ACT. † Rates assume premiums are currently and will continue to be remitted in advance of the effective date. Rates include insurance premiums and administrative fees for continuation, enrollment and materials

16 EBD GHINRPCS 1013

TransChoice® Advance Group Limited Benefit Hospital Indemnity Insurance Hospital Indemnity Benefit When a covered person is confined in a hospital as a result of an accident or sickness, this benefit pays the benefit amount for each day the insured is confined in a hospital, up to a maximum of 31 days per confinement.

Surgical and Anesthesia Indemnity Benefit We will pay the inpatient, an outpatient or an outpatient minor surgical benefit described for a covered person when a covered surgery is performed because of an accident or a sickness. The inpatient benefit is payable once per calendar year per covered person for any covered inpatient surgical procedure or for two or more inpatient procedures performed in the same surgical session. The outpatient benefit is payable once per calendar year for any covered outpatient surgical procedure or two or more outpatient procedures performed in the same surgical session. The outpatient minor benefit is payable once per calendar year per covered person for any covered outpatient minor surgical procedure or two or more such procedures performed in the same surgical session. We will also pay the anesthesia benefit when anesthesia is administered during any covered surgery. The indemnity benefit will be a percentage of the amount paid under the surgical indemnity benefit. Please see the certificate for a list of codes that are considered outpatient minor surgical procedures.

Hospital Confinement This benefit pays an additional benefit per covered person per calendar year when he/she receives treatment or surgery while confined to a hospital as an inpatient as a result of a covered accident or sickness.

Off-the-Job Accidental Injury Benefit This benefit pays the selected amount per day accident (maximum of 5 days per covered person per calendar year), for x-rays used to diagnose an accidental injury and for treatment of a covered accident by a physician in the physician’s office, clinic, urgent care facility, or hospital emergency room. Treatment must be received within 72 hours of the accident for benefits to be payable.

Intensive Care Indemnity Benefit This benefit pays per day for confinement in an intensive care unit, for a maximum of 31 days per covered person per calendar year. This benefit is paid in addition to the Daily In-Hospital Indemnity Benefit.

Non-Insurance Benefits: Employee Discount Card

This discount card is provided by New Benefits, LTD. It offers employees access to a discount Vision Plan, a Nurses Hotline, Counseling Services and benefits for Hearing Aids. This is not an insurance plan. The discount Vision Plan through the Coast to Coast network allows the employee to receive discounts of 20% to 60% on eyeglasses, non-prescription sunglasses, contact lenses (including disposables) and frames from over 10,000 independent retail optical locations nationwide. Providers include independent practitioners, regional chains, department store opticals, and the largest chains in the U.S. Some of these providers are LensCrafters, Pearle Vision, Sears Optical and JC Penney Optical (among others).* The Nurses Hotline allows access to experienced registered nurses 24 hours a day, 7 days a week, 365 days a year. These hotline nurses are an immediate, reliable and caring source of health information, education and support. Services provided by this plan include: General information on all types of health concerns Information based on physician-approved guidelines Answers about medication usage and interaction Information on non-medical support groups Translation services for non-English speaking callers Full time medical director on staff

The Counseling Services benefit allows the employee to speak with a counselor 24 hours a day, 7 days a week regarding any personal problems they may be facing. In addition, if the employee is referred to one of the 27,000 counseling providers nationwide, they will receive discounts of 25% to 30% off the normal billing charges from those providers.*

► ► ► ► ►

The Hearing Aid benefit provides savings of up to 15% off the retail cost on over 70 models of hearing aids, and a free hearing test when utilizing one of the 1,200 participating Beltone® locations nationwide. Or, the employees can realize savings of up to 50% off suggested retail price on over 90 models of hearing aids in over 1,000 locations nationwide.*

►

Information on how to access the benefits of the Employee Discount card will be included in the fulfillment package that each insured employee receives from TPA. * Discounts on professional services are not available where prohibited by law.

17 EBD GHINRPCS 1013

Patient Advocacy

Even with exceptional PPO discounts and rich reimbursement schedules, employees of limited benefit medical plans may be left with unpaid medical bills in years when medical bills approach $3,500 or more. For these individuals, Karis can come alongside to advocate on their behalf, working with every provider to find a mutually agreeable solution. Karis’ highly trained and experienced “Employee Advocates” guide employees through the tangled maze of medical billing. Initially, we research the availability of entitlement or financial assistance programs in an effort to locate outside funding sources to help pay their bills. If an employee qualifies for such programs, their Employee Advocate will hold their hand throughout what can be a lengthy process and will do everything for the employee from acquiring necessary paperwork to chasing decision makers. If an employee does not qualify for entitlement or financial assistance programs, their Employee Advocate will try to negotiate a reduced settlement or reduced/ extended payment plan with providers that is acceptable to all parties.

Teladoc

TelaDoc is a national network of board certified physicians providing telephonic cross coverage consultations 24/7 when your primary care physician is not available. Consulting physicians use electronic health records (EHRs) to diagnose routine medical problems, recommend treatment and may prescribe short-term, non DEA controlled prescriptions, when appropriate. Members simply make a phone call and in most cases, speak to a physician in about 30 minutes (3 hours guaranteed). TelaDoc™ Disclaimers: TelaDoc does not replace the primary care physician. TelaDoc is not available in Oklahoma. TelaDoc does not guarantee that a prescription will be written and operates subject to state regulations. TelaDoc does not prescribe DEA controlled substances. TelaDoc physicians reserve the right to deny care for potential misuse of services. TelaDoc, Inc. © 2002-2010

Limitations and Exclusions: Confinement for the same or related condition within 30 days of discharge will be treated as a continuation of the prior confinement. Successive confinements separated by more than 30 days will be treated as a new and separate confinement. No benefits under this contract will be payable as the result of the following:  Suicide or attempted suicide, whether while sane or insane.  Intentionally self-inflicted injury.  Rest care or rehabilitative care and treatment.  Immunization shifts and routine examinations such as: physical examinations, mammograms, Pap smears, immunizations, flexible sigmoidoscopy, prostate-specific antigen tests and blood screenings (unless Wellness Indemnity Benefit Rider is included).  Any pregnancy of a dependent child including confinement rendered to her child after birth.  Routine newborn care (unless Wellness Indemnity Benefit Rider is included).  A covered person’s abortion, except for medically necessary abortions performed to save the mother’s life  Treatment of mental or emotional disorder (unless Inpatient Mental and Nervous Disorder Indemnity Benefit Rider is included).  Treatment of alcoholism or drug addiction (unless Inpatient Drug and Alcohol Addiction Indemnity Benefit Rider is included).  Participation in a felony, riot, or insurrection.  Any accident caused by the participation in any activity or event, including the operation of a vehicle, while under the influence of a controlled substance (unless administered by a physician or taken according to the physician’s instructions) or while intoxicated (intoxicated means that condition as defined by the law of the jurisdiction in which the accident occurred).  Dental care or treatment, except for such care or treatment due to accidental injury to sound natural teeth within 12 months of the accident and except for dental care or treatment necessary due to congenital disease or anomaly.  Sex change, reversal of tubal ligation or reversal of vasectomy.  Artificial insemination, in vitro fertilization, and test tube fertilization, including any related testing, medications or physician’s services, unless required by law.  Committing, attempting to commit, or taking part in a felony or assault, or engaging in an illegal occupation.  Traveling in or descending from any vehicle or device for aerial navigation, except as a fare-paying passenger in an aircraft operated by a commercial airline (other than a charter airline) on a regularly scheduled passenger trip.  Any loss incurred on active duty status in the armed forces. (If you notify us of such active duty, we will refund any premiums paid for any period for which no coverage is provided as a result of this exception.)  An accident or sickness arising out of or in the course of any occupation for compensation, wage or profit or for which benefits may be payable under an Occupational Disease Law or similar law, whether or not application for such benefits has been made.  Involvement in any war or act of war, whether declared or undeclared

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Termination of Insurance The insurance terminates on the earliest of: • The insured’s death. • The premium due date when we fail to receive a premium, subject to the grace period. • The date of written notice to cancel coverage. • The date the policy terminates, subject to the portability option. • The date the insured ceases to be eligible for coverage. Dependent coverage ends on the earliest of: • The date the insured’s coverage terminates for any of the reasons above. • The date the dependent no longer meets the definition of a dependent. • The premium due date when we fail to receive a premium, subject to the grace period. • The date of written notice to cancel coverage. • The date the policy is modified so as to exclude dependent coverage. The insurance company has the right to terminate the coverage of any insured who submits a fraudulent claim. Termination will not impact any claim which begins before the date of termination.

Extension of Benefits

Whenever termination of coverage under this section occurs due to termination of Your employment or membership, such termination will be without prejudice to: 1. 2.

Any Hospital Confinement which commenced while coverage was in force, with respect to Daily In-Hospital Indemnity Benefits; or, Any covered treatment or service for which benefits would be provided and which commenced while coverage was in force; provided, however, that the Covered Person is and continues to be Hospital Confined or Disabled.

Such Extension of Benefits will continue for up to the earlier of: 1. 30 days; or 2. The date on which the Covered Person is no longer Disabled.

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Frequently Asked Questions Can I Sign Up For Coverage At Any Time? No. You must sign up for coverage in the first 30 days of your date of hire. If you do not elect coverage in the first 30 days, you will not be able to enroll until the next open enrollment period unless you experience a qualifying event.

How Can You Participate? All part-time employees and full-time employees who do not meet the eligibility requirements of the group benefit program (i.e. checkers, stockers, carryout, grocery clean up, janitors, or otherwise eligible to a union bargaining agreement) are eligible to enroll. Eligible dependents include spouses and unmarried children or stepchildren, under age 26.

Can I Cancel Coverage At Any Time? Premiums are paid with pre-tax dollars through payroll deductions as part of a Section 125 Savings Plan. You will not be able to change these elections until the next annual enrollment period, unless you have a Qualifying Event.

How Are Premium Payments Made? Premiums will be taken through payroll deduction. If you miss a payroll deduction as a result of absence or lack of work, coverage will be terminated and you will not be eligible to re-enroll until the next open enrollment period unless you experience a qualifying event.

When will my coverage begin? Coverage will begin the 1st of the month following your date of hire.

What Is An Indemnity Benefit? It means that the insurance company will pay a set amount each time the insured receives a covered service. The same amount is paid regardless of the fees charged by the provider.

When Will My Coverage End? Your coverage will end when you no longer qualify for the coverage or when your premium payments end, whichever comes first. Coverage on dependents ends on either the date they no longer meet the definition of a dependent or, the date your coverage terminates, whichever comes first.

When can I expect to receive the Member Kit? The member kit will typically be mailed to you approximately 7-10 business days after your first payroll deduction. Please allow three weeks for this kit to arrive in your mailbox.

Call 877-544-4297 to ask questions and enroll Customer Service Contacts

KeySolution Minimum Essential Coverage: Claims Key Benefit Administrators, Inc. P.O. Box 1279, Fort Mill, SC, 29716

TransChoice® Plus Hospital Indemnity Insurance: Claims Key Benefit Administrators, Inc. P.O. Box 1279, Fort Mill, SC, 29716

PPO Network: Offered through Key Benefit Administrators, Inc. Multiplan PPO Network 1-866-680-7427 or www.multiplan.com 20